2012 ARIN FALL SYMPOSIUM

Y-90 RADIOEMBOLIZATION

Y-90 RADIOEMBOLIZATION

• What is Yittrium-90 Radioembolization?

for the treatment of metastic liver cancer

• From the Radiologist’s perpective• From the Nurses’s point of view • From the Technologist’s perpective• From the Patient’s perpective•

WHAT IS RADIOEMBOLIZATION?

• Radiation therapy and embolization to treat cancer of the liver.

• Embolization is used to occlude blood flow. • Radiation therapy uses ionizing radiation to kill

cancer cells and shrink tumors. • Radioembolization involves placing a radioactive

material, tiny glass or resin beads called microspheres directly at the tumor site.

INDICATIONS

• Hepatocellular carcinoma

• Metastatic disease• Colorectal• Neuroendocrine• Cholangiocarcinoma• Breast• Melanoma• Others

MECHANISM OF ACTION

• There are two primary blood vessels that bring blood to the liver. Normal liver tissue receives about 75 % of its blood supply from the portal vein and about 25 percent from the hepatic artery and its branches. When a tumor grows in the liver, it receives almost all of it receives almost all of its blood supply from the hepatic artery.

• Radioactive microspheres are delivered through the hepatic artery, so they reach the tumor directly.

MECHANISM OF ACTION

• Particles introduced via hepatic artery catheter

• Tumor perfusion 3 – 17 fold higher than liver parenchyma

• Preferential flow to tumor vessels

• Particles trapped in tumor capillary bed.

HCC: RADIOGRAPHIC RESPONSE

Baseline 3 months later

Geschwind, et al. Gastroenterology 2004; 17: S194

HCC: RADIOGRAPHIC RESPONSE

Baseline 3 months later

Geschwind JF, et al. Gastroenterology 2004; 17: S194

USUALLY QUOTED HCC RESPONSE

IMAGING RESPONSE: PET

Before3 months after

BIOCHEMICAL RESPONSE: CEA

CLINICAL RESPONSE

• Symptom relief: 50% at 3 and 6 months

• Radioembolization is a treatment, not a cure.

• Sufficient clinical evidence exists to support the safety and efficacy of radioembolization in the treatment of metastatic hepatic tumors. Patient selection, treatment, and post procedure care are key components for a successful outcome.

NURSING PERSPECTIVE

• Greet the patient with your cup full• Position your team in a positive light to

improve patient outcome• Represent relief• Represent confidence• Represent care• Be competent

NURSING STANDARD OF CARE

• ENVIRONMENT/SAFETY

• PRE-PROCEDURE NURSING ASSESSMENT OF PATIENT

• PROCEDURE NURSING ASSESSMENT and CARE

• POST PROCEDURE PATIENT CARE

Y-90 NURSING STANDARD OF CARE

Patient/Procedure Assessment Nursing Interventions

ENVIRONMENT/SAFETY

*Prior to patient admission: Evaluate Procedure room for functioning suction with Yankauer tip, airway supplies (nasal, oral and face mask), oxygen (nasal cannula & non-rebreather set-up) & Ambu bag Ensure monitoring equipment is working properly.

*Replace missing items as needed. *Ensure availability of various sizes of oral/nasal airways/face masks, Ambu bag

*Location of emergency numbers/code button

*Location and integrity of emergency cart/emergency medications

Have emergency drug box available and supplies ready for emergency use.

The exam table is clean and prepared for a procedure. Radiology staff is responsible to clean and disinfect all x-ray and exam table surfaces with Sani-wipe clothes. All patient care items are disposable after use.

Y-90 dose is prepared in Nuclear Medicine. • Dose prepared in nuclear medicine and brought into IR room • Case done in IR Room 10. The room is secured, no entry is allowed by non-involved staff. • Place disposable drapes to capture potential spills of Y-90. • Alert radiation safety officer and nuc med staff in case of spill

(refer to Radiation Safety Handbook)

PRE-PROCEDURE NURSING ASSESSMENT

• Standard pre-procedure nursing assessment.

• Assess home and family living situation, children in the house, responsible adult in the house

• Contrast precautions-Patients will be screened for the risk of allergies and risk of contrast induced nephropathy. Pre-medication is given for patients with known allergies. Following contrast administration guidelines for checking creatinine and eGFR levels.

• Patient education starts PRIOR to the procedure.

Y-90 NURSING STANDARD OF CARE

PRE-PROCEDURE NURSING ASSESSMENT OF PATIENT

Nursing Intervention

Use the Nursing Assessment to evaluate patient and document,

*Obtain/validate medical history to include allergies, previous anesthetic/sedation problems *Identify and document nursing problems and interventions Check Surgical consent; blood consent (if indicated); H & P within 30 days of procedure with a 24 hour update if needed;

Pre-Procedure: The team suspends all other activities and participates in the Universal Protocol checklist.

Time out form

Radiation protection: Patients of childbearing age will be screened for pregnancy. Gonadal shielding will be placed under the table pad per policy. ALARA will be used. All staff will wear lead protection.

Contrast precautions: Patients will be screened for the risk of allergies and risk of contrast induced nephropathy. Pre-medication is given for patients with known allergies. Following contrast administration guidelines for checking creatinine and eGFR levels.

Patient Education Review patient education information with patient and family to answer any questions they may have. Prepare post procedure written instructions to be given after the procedure is completed.

PROCEDURE NURSING ASSESSMENT

• Patient positioning• Monitoring • Preparation of sterile tray and supplies• Prepping and Draping• Patient Skin prep• Positioning support• Airway management • Pain Management • Antibiotic Prophylaxis• Arterial Access• Hydration

Y-90 NURSING STANDARD OF CAREPROCEDURE NURSING ASSESSMENT Nursing Intervention

Patient positioning: Patient is to lie supine on the table.

Support bony prominences with cushioning.

Monitoring: Monitor EKG, BP, O2 sat, capnography, respirations, level of consciousness, and physical response to sedation / procedure.

Monitor vital signs and patient response to procedure continuously.

Preparation of sterile tray and supplies Sterile technique used and maintained throughout procedure

Prepping and Draping: The patient is prepped and draped for the procedure. Sterile practices are in place in the sterile field.

Sterile techniques and practices are observed in the sterile area

Patient Skin prep Chlorhexadine scrub - Pour Hibiclens (chlorhexadine) onto sterile 4x4 sponge gauge and apply to skin in a circular fashion, scrub to cleanse the skin for 60 seconds.

Positioning support: Patients are on a narrow table.

Wedge cushions and Velcro straps are used around the patient to ensure that the patient is safely and properly positioned for the procedure.

Airway management: Observe constantly for open and clear airway.

Suction is to be ready for suctioning of oral secretions at all times. Prompt assessment and intervention by a well-trained team and appropriate use of available equipment for monitoring and airway support are essential in preventing iatrogenic complications.

Y-90 NURSING STANDARD OF CARE

• Pregnant care providers should not take care of patients undergoing Y-90 procedures.

• Wear shoe covers when entering the procedure room. Wear gloves when touching the patient or covers. After radiation has been administered, maintain a distance of 3 feet or more from patient when possible. Approach the patient from the LEFT side, when possible.

• Staff will have knowledge about how to manage spills • In the event of a spill, contain contaminated areas and

persons inside the room until cleared by EH&S or Nuclear Medicine. Restrict the area. Keep people two meters away from the spill. Wash affected areas with water until EH&S deemed acceptable. Remove contaminated clothing while still in the area. Remove and properly contain contaminated materials and identify as radioactive.

ENVIRONMENTAL SAFETY

• Dose prepared in Nuclear Medicine and brought into IR room

• The room is secured, no entry is allowed by non-involved staff.

• Place disposable floor coverings and drapes to capture potential spills.

• Alert radiation safety officer and Nuclear Med staff

RADIATION SAFETY

NURSING PERSPECTIVE

• Medications used during Y-90• Antibiotics• Corticosteroids• Proton-pump inhibitors• Analgesics• Antiemetics

ENVIRONMENTAL SAFETY

RADIATION SAFETY: RECOVERY

• Y90 is safe for caregivers• Beta particle penetration in tissue 2.5 mm• Low-dose Bremsstrahlung scatter• Typical surface dose 2-10 mrem/hr• Typical dose at 1 meter 0.1-0.5 mrem/hr• Safe dose < 100 mrem

PATIENT RECOVERY

• Minimize time and Maximize distance• Reasonable precautions

• Stay more than 3 feet away from the patient• Do not approach patient from treated side• Minimize handling of urine (SIR-Sphere only).

ROAD TO RECOVERY

• Patient follow up in clinic• Post procedure phone calls• Patient instructions• Help patients look towards the future

NUCLEAR MEDICINE TECH ROLE

The Nuc Med Tech receives, prepares and assists with the administration of the Y90. It is our responsibility to make sure the isotope, amount of activity, patient identification and orders are all correct for the procedure.

Through all of this, we also make sure radiation safety rules are followed so exposure to IR personnel is minimized.

NUCLEAR MEDICINE TECH ROLE

Receive Y90 and add to inventoryMeasure Y90 activity prior to administrationVerify correct activity is drawn for procedure

Measure exposure rate of dosePrepare supplies needed for administration

Assist with verbal instructions during admin.Verify procedures during administrationPost measurement of dose after admin.

Calculate Y90 dose given to patientAlways follow ALARA principles

YTTRIUM-90

• Pure beta-emitter• Average particle energy 0.9367 MeV• Average penetration in tissue 2.5 mm• Physical half-life 64.2 hours (2.7 days)• Decays to zirconium-90 at deposition site• Minimal (< 2%) renal excretion (SIR-sphere).

Y-90 AGENTS

1Approved under Humanitarian Device Exemption (HDE). Administration requires Institutional Review Board oversight

LUNG TOXICITY PREVENTION

• TheraSphere contraindicated if• Normal pulmonary reserve

• Lung dose > 30 Gy per treatment• Lung dose > 50 Gy cumulative

• COPD• Lung dose > 15 Gy per dose• Lung dose > 30 Gy cumulative

• SIR-Sphere

DETERMINE LUNG SHUNT FRACTION

• Tc-99m macroaggregated albumin (MAA) perfusion scan• MAA particles 10-90 μm• 1 mCi injected via hepatic artery catheter• Lung shunt fraction calculated• Y-90 dose depends on LSF

LOW LSF

HIGH LSF

ROOM PREPARATION

• Absorbent paper taped to the floor• Universal precautions

• Cap and gown• Double gloves• Double shoe covers

• Radiation safety officer in the room• Plastic “mayo jar” with acrylic shield.

THERASPHERE ADMINISTRATION SET

SIR-SPHERE ADMINISTRATION SET

Maximize distance from delivery unitUse additional shieldingFoot covers

MEASURE DOSE EXPOSURE RATE

MEASURE POST DOSE EXPOSURE

MEASURE AND COVER SPILLS

PATIENT’S PERSPECTIVE

• Life is put on hold and things are out of control

• The information is overwhelming• Feeling desperate and a sense of despair• Too many questions without answers

• Will I survive? How? Who’s going to…..• What does all this mean?• The medications?....• The appointments?....• Will I have pain?

PATIENT’S PERSPECTIVE

• Patients with advanced liver cancer have few options, so this offers optimism. This is an option for patients who have been told they are not candidates for other treatments. It gives patients hope, which is a magical thing.

• The aim is to extend life and feel better, even though it’s not a cure. In some cases, it may allow for more curative options such as surgery or liver transplantation.

• It is a minimally invasive procedure, and patients can go home several hours after the treatment.

FROM THE PATIENT’S PERSPECTIVE

How much does this cost?This does effect the patient’s experience.

• The estimate for the Y90 is $106,212.66.• This includes pro fees, lab, pharmacy, supplies.

PATIENT’S PERSPECTIVE

• Sedation and pain medication is helpful because the procedure can last over an hour.

• Few patients experience some side effects called

post-embolization syndrome, including nausea, vomiting and fever. These side effects usually subside within three to five days and may be alleviated with medication.

PATIENT INSTRUCTIONS

• Sleep alone x 3 days• Abstain from work x 3 days• Maximize distance to caregivers x 3 days• Limit contact with children x 12 days.